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Request for Self-Insurance Letters

This self-insurance request form is provided for the use of District government agencies ONLY.

The Government of the District of Columbia operates as a self-insured entity. When a DC Agency requires proof of insurance (evidence of self-insurance), the DC Office of Risk Management (ORM) will review and consider all requests for such proof. Please understand that all requests for proof of insurance letter shall be requested at least ten (10) days prior to its due date.

Please complete the following information for the Office of Risk Management to prepare the letter of self-insurance.

If you have any questions about the process of requesting self-insurance letters, please email jed.ross2@dc.gov.

Do not request a self-insurance letter by email or fax.

Date of Request

Month

Day

Year

Name of Agency

Agency Representative - Phone Number

Agency Representative - Email Address

Address of Agency

Event Description

Type of event

Event Time Start

:

am

pm

Event Time End

:

am

pm

Event Date

Month

Day

Year

Estimated Number of Attendees

Event Venue

Location

Venue Contact - Name

Venue Contact - Phone Number

Venue Contact - Email Address

Venue Address

Attachments (Allowed file extensions are txt, pdf, doc and docx only)

(Contract, marketing material, etc. Upload all relevant attachments)

Special Instructions

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